Provider Demographics
NPI:1255741674
Name:OBRIEN, TIMOTHY (LAT, ATC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:OBRIEN
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 3RD ST NE
Mailing Address - Street 2:MAYVILLE STATE UIVERSITY
Mailing Address - City:MAYVILLE
Mailing Address - State:ND
Mailing Address - Zip Code:58257-1217
Mailing Address - Country:US
Mailing Address - Phone:701-788-4844
Mailing Address - Fax:701-788-4840
Practice Address - Street 1:330 3RD ST NE
Practice Address - Street 2:MAYVILLE STATE UIVERSITY
Practice Address - City:MAYVILLE
Practice Address - State:ND
Practice Address - Zip Code:58257-1217
Practice Address - Country:US
Practice Address - Phone:701-788-4844
Practice Address - Fax:701-788-4840
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND103-922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer